THERAPY-Magazin
Intradialytic exercise
Learn how intradialytic exercise enhances muscle strength, reduces hospital stays, and improves quality of life in dialysis patients. Explore the promising DiaTT study and the role of devices like the THERA-Trainer bemo.
Jakob Tiebel
Business Owner, N+ Digital Health Agency
Movement as medicine during haemodialysis
Background
About half a million Americans have chronic kidney disease and are regularly dependent on haemodialysis (HD). During HD, waste, salt and fluid are filtered from the blood of patients via an artificial kidney called a dialyser. The number of HD patients in America is identical to that of many European countries. Globally, a substantial increase in the number of people requiring dialysis is predicted by 2040, accompanied by a steady increase in the cost of care [8,23].
Most patients receive dialysis through direct access to the bloodstream. This can be via a central venous catheter, an arteriovenous fistula or a synthetic arteriovenous graft. Most patients opt for inpatient HD treatment, which usually takes place three times a week and lasts an average of 4 hours. Alongside this, patients must adhere to strict fluid and nutritional guidelines to protect their cardiovascular system, bones and muscle mass. In addition, HD patients have been shown to have problems with their physical performance, which is why it has become widely accepted over the last ten years that HD patients should get as much exercise as possible – not just before or after, but especially during HD treatment.
About half a million Americans have chronic kidney disease and are regularly dependent on haemodialysis (HD). During HD, waste, salt and fluid are filtered from the blood of patients via an artificial kidney called a dialyser. The number of HD patients in America is identical to that of many European countries. Globally, a substantial increase in the number of people requiring dialysis is predicted by 2040, accompanied by a steady increase in the cost of care [8,23].
Most patients receive dialysis through direct access to the bloodstream. This can be via a central venous catheter, an arteriovenous fistula or a synthetic arteriovenous graft. Most patients opt for inpatient HD treatment, which usually takes place three times a week and lasts an average of 4 hours. Alongside this, patients must adhere to strict fluid and nutritional guidelines to protect their cardiovascular system, bones and muscle mass. In addition, HD patients have been shown to have problems with their physical performance, which is why it has become widely accepted over the last ten years that HD patients should get as much exercise as possible – not just before or after, but especially during HD treatment.
Long-term haemodialysis treatment has a catabolic effect on the muscles. This results in reduced quality of life and everyday independence, an increased risk of falls and a shortened life expectancy.
The typical HD patient
Long-term haemodialysis treatment has a catabolic effect on the muscles. This results in reduced quality of life and everyday independence, an increased risk of falls and a shortened life expectancy. Nutritional factors, hormonal changes, inflammation, metabolic acidosis, neuropathies, inactivity and complications from various comorbidities also contribute to accelerated muscle loss [11,27].
Due to the consequences and comorbidities, the risk of hospitalisation increases. A typical HD patient spends an average of 11 days per year in hospital. In addition, HD patients have a 37% higher risk of being readmitted to hospital within one month. Recurrent hospitalisations set a negative spiral in motion. They lead to further muscle atrophy, which, together with an estimated immobilisation of 4 to 6 weeks per year, contributes to an even greater decline in physical performance [4,23].
Increasing activity levels is therefore one of the most promising solutions to counteract muscle atrophy and associated reduced physical functions. The remedy of choice: Regular mobility training, which is either extradialytic (outside dialysis treatment) or intradialytic (during dialysis). Reports indicate that while extradialytic training can bring greater benefits in terms of physical performance and functional abilities, compliance is lower compared to intradialytic interventions.
Long-term haemodialysis treatment has a catabolic effect on the muscles. This results in reduced quality of life and everyday independence, an increased risk of falls and a shortened life expectancy. Nutritional factors, hormonal changes, inflammation, metabolic acidosis, neuropathies, inactivity and complications from various comorbidities also contribute to accelerated muscle loss [11,27].
Due to the consequences and comorbidities, the risk of hospitalisation increases. A typical HD patient spends an average of 11 days per year in hospital. In addition, HD patients have a 37% higher risk of being readmitted to hospital within one month. Recurrent hospitalisations set a negative spiral in motion. They lead to further muscle atrophy, which, together with an estimated immobilisation of 4 to 6 weeks per year, contributes to an even greater decline in physical performance [4,23].
Increasing activity levels is therefore one of the most promising solutions to counteract muscle atrophy and associated reduced physical functions. The remedy of choice: Regular mobility training, which is either extradialytic (outside dialysis treatment) or intradialytic (during dialysis). Reports indicate that while extradialytic training can bring greater benefits in terms of physical performance and functional abilities, compliance is lower compared to intradialytic interventions.
Globally, a substantial increase in the number of people requiring dialysis is predicted by 2040, accompanied by a steady increase in the cost of care.
Therefore, intradialytic training, usually performed during the first 2 hours of HD treatment, is a useful non-pharmacological “medicine” for HD patients. The best known example of intradialytic mobility training is the use of a cyclic movement exerciser, such as the THERA-Trainer bemo. The training device is positioned in front of the treatment chair or at the foot of a bed and allows cycling to be performed during HD in a lying position [7,13,18].
Benefits of intradialytic exercise
Research on intradialytic movement has been conducted for more than 30 years. Many of these studies have been summarised in systematic reviews [2,3,9,10,14,24,25,26,32].
The results suggest that dialysis adequacy improves especially when exercise is performed during HD. Intradialytic cycling can increase blood flow to the working leg muscles. This transports the trapped urea (and other toxins) from the muscle compartments into the bloodstream to be effectively filtered out during HD [12,22].
Research results also show improvements in fatigue, depression, quality of life, sleep, inflammation and hospitalisation [1,15,17,19,21,30]. Although the methods are very different and the significance is usually low with small groups of subjects, the general consensus in the literature leans towards intradialytic exercise being at least better than complete passivity during HD lasting several hours. However, a future shift towards larger, multi-centre studies with precise training intensities and durations still needs to increase the strength of evidence on intradialytic training [21].
A working group led by Stefan Degenhardt and Kirsten Anding-Rost from Germany is making an important contribution to the proof of efficacy of intradialytic exercise with its multi-centre DiaTT study [29]. The abbreviation DiaTT stands for Dialysis Training Therapy. In contrast to care in Germany and other countries in Europe and the world until now, the DiaTT study design consistently integrates an individualised physical training programme during each haemodialysis session.
The aim of the DiaTT study is to investigate the effects of a 12-month intradialytic exercise programme on physical functioning, frailty and health economics in a large cohort of HD patients in a real-world setting. DiaTT is a prospective, cluster-randomised (1:1), controlled, multi-centre, clinical intervention study in 28 dialysis units with the aim of recruiting >1100 HD patients. The DiaTT will thus be the largest randomised controlled trial to assess frailty, quality of life and mortality in the field of nephrology, as almost as many patients will be included as have previously been studied in total in smaller studies [29].
If the researchers’ hypotheses are confirmed, the results will drastically support the previous assumption that physical activity during dialysis improves mobility, quality of life and medical parameters, and the measures simultaneously contribute to a reduction in outpatient and inpatient medical costs. The study was launched in 2018. In January 2020, patient inclusion was completed in all participating centres. In fact, about 1,350 patients could be included in this large-scale study. The results, which will be ground-breaking for the future of intradialytic exercise, are now eagerly awaited [29].
Research on intradialytic movement has been conducted for more than 30 years. Many of these studies have been summarised in systematic reviews [2,3,9,10,14,24,25,26,32].
The results suggest that dialysis adequacy improves especially when exercise is performed during HD. Intradialytic cycling can increase blood flow to the working leg muscles. This transports the trapped urea (and other toxins) from the muscle compartments into the bloodstream to be effectively filtered out during HD [12,22].
Research results also show improvements in fatigue, depression, quality of life, sleep, inflammation and hospitalisation [1,15,17,19,21,30]. Although the methods are very different and the significance is usually low with small groups of subjects, the general consensus in the literature leans towards intradialytic exercise being at least better than complete passivity during HD lasting several hours. However, a future shift towards larger, multi-centre studies with precise training intensities and durations still needs to increase the strength of evidence on intradialytic training [21].
A working group led by Stefan Degenhardt and Kirsten Anding-Rost from Germany is making an important contribution to the proof of efficacy of intradialytic exercise with its multi-centre DiaTT study [29]. The abbreviation DiaTT stands for Dialysis Training Therapy. In contrast to care in Germany and other countries in Europe and the world until now, the DiaTT study design consistently integrates an individualised physical training programme during each haemodialysis session.
The aim of the DiaTT study is to investigate the effects of a 12-month intradialytic exercise programme on physical functioning, frailty and health economics in a large cohort of HD patients in a real-world setting. DiaTT is a prospective, cluster-randomised (1:1), controlled, multi-centre, clinical intervention study in 28 dialysis units with the aim of recruiting >1100 HD patients. The DiaTT will thus be the largest randomised controlled trial to assess frailty, quality of life and mortality in the field of nephrology, as almost as many patients will be included as have previously been studied in total in smaller studies [29].
If the researchers’ hypotheses are confirmed, the results will drastically support the previous assumption that physical activity during dialysis improves mobility, quality of life and medical parameters, and the measures simultaneously contribute to a reduction in outpatient and inpatient medical costs. The study was launched in 2018. In January 2020, patient inclusion was completed in all participating centres. In fact, about 1,350 patients could be included in this large-scale study. The results, which will be ground-breaking for the future of intradialytic exercise, are now eagerly awaited [29].
Barriers in relation to practical implementation
Despite the anticipated benefits and recommendations to increase exercise during HD, there are still few established intradialytic exercise programmes in standard care. The Dialysis Outcomes and Practice Patterns Study (DOPPS), which examined HD institutions in 12 countries, shows that Germany, Sweden, Australia, New Zealand and Canada already offer intradialytic training programmes. However, the number of facilities that regularly conduct intradialytic exercise is still less than 20 per cent, so there is still a great need. Possible obstacles to consistent implementation must be identified and removed in this context in order to consistently increase the amount of training offered [16,28].
Funding problems, staff workload and lack of equipment were cited as the main barriers to running intradialytic exercise programmes. Other concerns include nephrologists’ perceptions of safety and insufficient knowledge about exercise [16,26,31]. Interestingly, in a survey of 198 nephrologists, Delgado and Johansen [5] found that 100% of respondents thought physical activity was important for their patients; however, 35% did not think their patients would be open to a conversation about physical activity. Ironically, in a study by the same authors two years later, only 4% of patients with renal failure said they were not interested in this topic. These patients strongly believed that exercise is important, and 93% said they would be likely to exercise more if their doctor or a healthcare professional guided them in taking this “medicine” [6].
Despite the anticipated benefits and recommendations to increase exercise during HD, there are still few established intradialytic exercise programmes in standard care. The Dialysis Outcomes and Practice Patterns Study (DOPPS), which examined HD institutions in 12 countries, shows that Germany, Sweden, Australia, New Zealand and Canada already offer intradialytic training programmes. However, the number of facilities that regularly conduct intradialytic exercise is still less than 20 per cent, so there is still a great need. Possible obstacles to consistent implementation must be identified and removed in this context in order to consistently increase the amount of training offered [16,28].
Funding problems, staff workload and lack of equipment were cited as the main barriers to running intradialytic exercise programmes. Other concerns include nephrologists’ perceptions of safety and insufficient knowledge about exercise [16,26,31]. Interestingly, in a survey of 198 nephrologists, Delgado and Johansen [5] found that 100% of respondents thought physical activity was important for their patients; however, 35% did not think their patients would be open to a conversation about physical activity. Ironically, in a study by the same authors two years later, only 4% of patients with renal failure said they were not interested in this topic. These patients strongly believed that exercise is important, and 93% said they would be likely to exercise more if their doctor or a healthcare professional guided them in taking this “medicine” [6].
Increasing activity levels is therefore one of the most promising solutions to counteract muscle atrophy and associated reduced physical functions.
The findings suggest that the challenges lie more in staff perceptions and not in patients’ opinions about exercise. It is likely that many patients see intradialytic exercise as a welcome distraction that can improve their self-esteem and their ability to actively participate in their own healthcare.
Final thoughts
Based on current evidence and empirical findings, national and international associations recommend that patients with renal insufficiency exercise for more than 30 minutes at moderate intensity on most days of the week.
Currently, the recommendations are mainly geared towards extradialytic exercise. Although there is still no scientific consensus on intradialytic exercise, all results from research and practice so far point to its usefulness in promoting a greater presence of movement during HD.
The results of the DiaTT study will be ground-breaking for the future of intradialytic exercise and are therefore eagerly awaited.
Based on current evidence and empirical findings, national and international associations recommend that patients with renal insufficiency exercise for more than 30 minutes at moderate intensity on most days of the week.
Currently, the recommendations are mainly geared towards extradialytic exercise. Although there is still no scientific consensus on intradialytic exercise, all results from research and practice so far point to its usefulness in promoting a greater presence of movement during HD.
The results of the DiaTT study will be ground-breaking for the future of intradialytic exercise and are therefore eagerly awaited.
bemo
Cycling
Dialyse Trainings-Therapie
Fachkreise
Science
THERAPY 2023-II
THERAPY Magazine
Jakob Tiebel
Business Owner, N+ Digital Health Agency
Jakob Tiebel studied applied psychology with a focus on health economics. He has clinical expertise from his previous therapeutic work in neurorehabilitation. He conducts research and publishes on the theory-practice transfer in neurorehabilitation and is the owner of Native.Health, an agency for digital health marketing.
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